Release of Information Form

HIPAA Transfer of Medical Records Request
Patient Name

First NameLast Name
Birth Date

MonthDayYear
Phone Number

Area CodePhone Number
Email
example@example.com
Reason for Transfer
Please release the following:

I would like the last two well visits with growth charts and updated immunizations.Other (see below)
Please release the following records:
Phone Number in case we need to reach you.

Area CodePhone Number
How would you like to receive your records?

In your patient portalYou will pick them up in the officeHave them faxed to your new physician
My new physician's fax is:
By completing and sending this medical records/transfer request, I release New Canaan Pediatrics from any further medical responsibility for my child. I understand that if I am not up to date with my Care Fee, I will be charged a fee of $0.65 per page for a paper copy as allowed by the State of Connecticut unless Medicaid rules apply.

Please note: The State of Connecticut privacy laws require that if the patient is 18 years old or older they must sign the request form in addition to the parent or guardian. Please note privacy information may be deleted at the discretion of your child's physician.

IMPORTANT: You need to notify your insurance company that you are changing your primary care provider to ensure continued coverage.
Parent/Guardian Signature

Clear
Patient 18 years or older signature

Clear
Date submitted

MonthDayYear
Date
Should be Empty:

HIPAA Transfer of Medical Records Request